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Introduction
Renal (ureteric) colic is a common surgical emergency. It is usually
caused by calculi obstructing the ureter, but about 15% of patients
have other causes, e.g. extrinsic compression, intramural neoplasia
or an anatomical abnormality [1]. Up to 12 percent of the population
will have a urinary stone during their lifetime, and recurrence rates
approach 50 percent [2]. Fifty-five percent of those with recurrent
stones have a family history of urolithiasis [3] and having such a history
increases the risk of stones by a factor of three [4]. Upon presentation
to the A&E department, suspected acute renal colic patients must have
a clinical examination and radiological investigations to confirm the
diagnosis [5].
The best imaging study to confirm the diagnosis of a urinary
stone in a patient with acute flank pain is unenhanced, helical CT of
the abdomen and pelvis [6]. If CT is unavailable, plain abdominal
radiography should be performed, since 75 to 90 percent of urinary
calculi are radiopaque [5]. Although ultrasonography has high specificity
(greater than90 percent), its sensitivity is much lower than that of CT,
typically in the range of 11 to24 percent [5]. Thus, ultrasonography is
not used routinely but is appropriate as the initial imaging test when
colic occurs during pregnancy [7]. Urgent intervention is indicated in
a patient with an obstructed, infected upper urinary tract, impending
renal deterioration, intractable pain or vomiting, anuria, or high-grade
obstruction of a solitary or transplanted kidney [5]. Infection proximal
to obstruction is suggested by fever, urinalysis showing pyuria and
bacteriuria, and leukocytosis, and the presence of urosepsis is associated
with an increased risk of complications [5]. Impaired glomerular
filtration inhibits the entry of antibiotics into the collecting system and
requires emergency decompression by means of either percutaneous
nephrostomy or ureteral stenting [8,9].
There are very strict guidelines produced by the BAUS and the
College of Emergency Medicine. Despite this, over a quarter of UK
A&E departments did not perform any radiological investigations
when patients presented with renal colic. Shockingly some departments
do not even offer renal colic patients any analgesia [5].
British Association of Urology Guidelines (2008) [10], specify
clinical assessment must exclude UTI/ AAA. Initial investigations must
include x-ray KUB, urinalysis and FBC/U+Es. Within 24 hours a Non
contrast CT must be conducted to confirm the diagnosis, or IVU if CT
is unavailable. In addition analgesia must be administered: NSAIDS/
Method
Over one year, we conducted a retrospective analysis of patient
notes admitted with renal colic to Worcestershire Acute Hospitals.
We will be collecting data on the following in order to see if clinical
practice was in line with guidelines:
Citation: Goonewardene SS , Rajjayabun P (2016) Acute Management of Renal Colic and Compliance with National Standards: Closure of the Audit Loop.
Arch Renal Dis Manag 2(1): 008-010.
008
Initial Investigations
o Patients should have a dipstick urinalysis performed and
the result recorded in the notes
o Patients should have FBC & renal function performed
and the result recorded in the notes before discharge
o Serum Calcium / Urate: Mandatory basic metabolic
studies if stones are present.
o X-ray KUB, non-contrast CT or IVU documented in
notes and whether CT was conducted within 24 hrs.
o Patients over 60 should have AAA excluded by
appropriate investigation
Results
40 cases were admitted to Worcestershire Acute Hospitals with
a diagnosis of renal colic. One patient declined analgesia (results
documented in notes). 25% had severe pain (10 cases, pain score 7-10),
time to analgesia 30 minutes. 25% had moderate pain (10 cases, score
4-6), time to analgesia was 40.4 mins. 50% had mild pain score (20
cases, pain score 1-5), time to analgesia 81.8 mins. 72.5% (29 patients)
had their pain re-assessed within one hour after receiving analgesia.
77.5% (31 patients) received appropriate analgesia (NSAID/ Opiate).
45% (18 patients) had clinical history/ examination to rule out UTI/
AAA. 100% of patients had urinalysis, but in 2 cases, results were not
documented in notes. 65% (21 cases) had X-ray KUB as the initial
investigation, 79% the same day, 9 cases then had NCCT. 75% (30
cases) had NCCT, 50% (15 cases) were the same day. 27.5% (11 cases)
had stones on CT. One case had an OP IVU. The Radiology plan
was documented in notes in 92.5% (37 cases). 100% had blood for
FBC and U+ES which were all documented in notes. Only 3 cases
had urate and calcium levels tested. 100% of cases had senior Urology
review.
We analyzed 32 case notes, from Dec 2009 to September 2010
admitted with a provisional diagnosis of renal colic to Worcestershire
Acute Hospitals. We demonstrated the mean time to analgesia from
triage for severe pain was 106 minutes, 62 minutes for moderate
pain and 46 minutes for mild pain. 84% received the appropriate
analgesic (NSAID/Opiate). The reasons for not giving analgesia were
documented in all cases. In only 18% (6 cases) pain was re-evaluated
Patients
32 patients
40 cases
Dates
84%
77.5%
Pain reassessment
Presence of stones
100% had blood for FBC and U+ES which were all documented in
notes
Initial investigation
CT within 24 hours
IVU
009
Citation: Goonewardene SS , Rajjayabun P (2016) Acute Management of Renal Colic and Compliance with National Standards: Closure of the Audit Loop.
Arch Renal Dis Manag 2(1): 008-010.
Discussion
Conclusion
We have demonstrated we are following guidelines in the majority
of patients, however can still improve service running with further
References
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Copyright: 2016 Goonewardene SS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
010
Citation: Goonewardene SS , Rajjayabun P (2016) Acute Management of Renal Colic and Compliance with National Standards: Closure of the Audit Loop.
Arch Renal Dis Manag 2(1): 008-010.